J Ayub Med Coll Abbottabad 2016;28(3)

CASE REPORT
IDENTIFICATION AND ENDODONTIC TREATMENT OF THREE-
CANALLED MAXILLARY FIRST PREMOLAR
Atif Saleem Agwan, Zeeshan Sheikh*
Department of Dentistry, Northern area Armed Forces Hospital, King Khalid Military City-Kingdom of Saudi Arabia, *Faculty of
Dentistry, University of Toronto, Toronto-Canada

Maxillary premolars exhibit variable root canal morphology, but it is quite rare to find three canals
in their root system. The aim of this case report is to present the diagnosis and clinical
management of a patient with anatomical variation of having three root canals in the maxillary
first premolar. Three–canalled maxillary premolars are quite an endodontic challenge. A
discussion is provided here to facilitate the early recognition of these canals, access cavity
modifications for better intra-canal preparation and obturation procedures. Clinicians are required
to be aware of the anatomical variations they may encounter when dealing with maxillary
premolars and should be trained to apply this knowledge in the clinical scenario.
Keywords: Maxillary First Premolar; Anatomical Variations; Root Anatomy; Endodontics
J Ayub Med Coll Abbottabad 2016;28(3):627–9

INTRODUCTION canals result in an anatomy of maxillary premolars

that resembles the adjacent molars and are therefore
In order to perform endodontic therapy successfully,
sometimes called ‘radiculous’ (small molars).10 It is
it is imperative that the clinicians should have an in-
very helpful to examine radiographs obtained from
depth knowledge of external and internal tooth
contralateral teeth to compare and identify when
anatomy. The lack of sufficient knowledge results in
suspecting a complex root configuration. The three
the misdiagnosis, error in identification and
rooted configuration of maxillary first premolars can
localization of the root canal systems present and
often be visualized on preoperative radiographs.9,11
incomplete or erroneous preparation and canal filling.
When employing straight-on radiographs the general
It is recommended that before initiating any
rule and guide for identification of the three-rooted
endodontic treatment, the clinician obtains 2 or 3
tooth is that if the mesial-distal width of the mid-root
radiographs from different angles to show and
image appears greater or equal to the mesial-distal
confirm the exact anatomical form and variation.1
width of the crown image, then three roots are most
Maxillary first premolars have a very
likely to be present. Though this guideline provides a
complex internal anatomy due to their inherent
good visual cue, it is not definitive. The closer
variation in root numbers and canal configuration
examination of extracted maxillary first premolars
(Figure-1).2,3 For the first maxillary premolars, the
with three roots in comparison with maxillary first
incidence of three canals is very low (~3–5%).4–6
premolars with two roots (two canals in buccal root,
Whereas, this three-canalled observation is about 1%
one in palatal) demonstrates how this guideline is
for maxillary second premolars.7 In a study
only valid for three-rooted premolars.9 The main aim
performed by Vertucci and Gegauff8 it was observed
of this case report is to present the identification and
that 5% of the 400 maxillary first premolars observed
endodontic management of a three-canalled maxillary
had three canals with 0.5% of these three canals
first premolar.
existing in a single root, 0.5% presented as two
canals in one root and one canal in second root, and CASE REPORT
4% were seen to exist as one canal in each of the
A 19 year old male patient was presented to the clinic
three roots. The three-canalled maxillary premolars
referred by another general dental practitioner with
are difficult to visualize on preoperative radiographs.
spontaneous pain in tooth # 14. The past and present
The general consensus is that the earlier these root
medical history was unremarkable. Clinically, it was
canal configurations of very complex nature can be
observed that the pulp was exposed by a carious
identified, the more likely it is that the clinician can
lesion in tooth #14. The tooth was sensitive to cold or
successfully perform the intracanal preparation and
electronic pulp testing with the response indicating
obturation.
towards irreversible pulp damage. A preoperative
The most common root canal configuration
periapical radiograph confirmed the presence of a
observed for the three-canalled maxillary first
carious lesion on the distal surface of tooth #14
premolar is the three separate roots, each consisting
(radiograph not available).
of a single canal classified as the mesiobuccal,
The evaluation of the periapical radiograph
distobuccal and the palatal canals.9 These three root
together with the position of the buccal canal orifice

http://www.jamc.ayubmed.edu.pk 627

suggested the possibility of the presence of a third
canal. Buccal canals in three-rooted premolars are
usually observed to lay close to each other and are
often covered and hidden by a projection of cervical
dentine.9,12 An Endo Access bur 3 A0164 (Dentsply
Maillefer, Ballaigues, Switzerland) was utilized to
modify the access opening edges to create a
triangular outline in the buccal direction. After
removing the coronal pulp, the floor was explored.
The buccal canals were explored with size 8 and 10
files and the palatal with a size 15 K file (Mani inc,
Japan). A periapical radiograph was taken (Figure-2)
to confirm the presence of three separate roots and
three separate canals (two buccal and one palatal).
Figure-1: The comparison between root
morphology of extracted maxillary premolars
with three root canals
Figure-2: Radiographic confirmation of the
independent trajectory of the three root canals
and their respective roots in tooth #14
Figure-3: Radiograph following the obturation of
the three root canals in tooth #14
628 http://www.jamc.ayubmed.edu.pk
J Ayub Med Coll Abbottabad 2016;28(3)
The working length was confirmed using an apex
locator. The buccal roots were prepared manually
using 8, 10 and 15 K files (Mani inc, Japan). Sizes 1,
2 and 3 Orifice shapers of the Proflie system
(Dentsply, Maillefer) were used to achieve the
counter-curve reduction of the cervical and middle
thirds. The apical third preparation was accomplished
with sizes 1-6 taper 0.04 instruments of the Profile
(Dentsply, Maellefer) series with copious irrigation
with 1% sodium hypochlorite. The buccal root canals
were shaped to a size 4 taper 0.04 instrument and the
palatal canal to a size 5 taper 0.04 instrument. After
cleaning and shaping, the canals were dried with
paper points (Roeko, Coltene/ Waledent-Germany)
and filled with gutta percha (Roeko,
Coltene/Waledent-Germany) and AH26 sealer
(Dentsply Dentry GmbH, Germany) by cold lateral
condensation (Figure-3). The access cavity was
sealed with composite (Filtek™ Supreme 3M ESPE).
Postoperative instructions and analgesic were given
and the patient was referred to a periodontist for
crown lengthening to prevent biologic width
violation before crown preparation would be carried
out.
DISCUSSION
The maxillary first premolars are among the most
challenging teeth to be managed via endodontic
therapy. The various reasons for this are: the varying
number of roots, number of canals, variations in pulp
cavity configuration, the longitudinal and directional
depressions present on the roots and limitation and
difficulty of visualization of apical limit on
radiographs.1 The acquisition of sufficient knowledge
of tooth, root canal and pulp morphology can lead to
improvement in endodontic therapy results.
Traditionally in the past many clinicians have treated
maxillary first premolars assuming that they have 2
canals. This concept has and should change now
since we know that although the incidence is low,
between 0.5–7.5% of these teeth possess 3
canals.1,6,13,14 We know that the root curvature
towards the buccal or lingual cannot be detected in
radiographs. This can result in perforations during
instrumentation. It has been shown that lingual root is
straight in about 24% and curve towards the buccal
side in 26% of the 2 rooted teeth.1 Also, the buccal
root being longer by almost 1 mm than the lingual
root has been seen.1,15 The recognition of variations
in length and curvatures of roots allows the clinician
to adjust his technique and instrumentation to avoid
iatrogenic perforations.
The foundation of successful endodontic
treatment is always dependent on achieving good
access.16,17 A cavity modification into a “T” shape
access cavity is required for the three-canalled

maxillary first premolar.9,18 This access cavity goes
from mesial to distal extending the buccal aspect of
the usual outline form.9 This modification results in
adequate access to the two buccal canals. Sometimes
the two buccal canals arise from a narrow common
canal that originates from the pulp chamber and this
creates an “S” shaped configuration that restricts
instrumentation as it is difficult to maintain that
shape.19,20 This situation can be negotiated by
creating and extending a trough 1–2 mm apically
over and between the buccal canals.9,20 This is similar
to pre-flaring during intra-canal preparation and
eliminates the “S” shaped canal rendering apical
canal instrumentation more manageable.9 Once the
access cavity has been prepared, intra-canal
preparation can be completed. Narrow buccal canals
should not be over-enlarged (to avoid “strip”
perforation) and should be negotiated with a #10
endodontic file till the full working length.9 Once the
intra-canal preparation is accomplished using step
back flaring, reverse flaring and/or reverse filing to
satisfaction, the obturation can be initiated and
completed.21,22
CONCLUSION
It is very important for clinicians to have a clear
knowledge of the anatomical variations in maxillary
premolars they may encounter. This knowledge has
to be applied towards successful radiographic and
clinical interpretation. Due to the complex anatomy
that may prevail, access cavity refinements are
usually required to achieve stress-free and
uncomplicated straight line access to the canals. The
saying that ‘what you don’t know doesn’t hurt you’
does not apply to dentistry and the field of
endodontics particularly. The lack of identification
which leads to missing the present extra canal often
leads to persistent pain encountered by the patients
after root canal therapy. The complex premolar
anatomical presentations require management
following accurate identification and negotiation.
REFERENCES
1. Pécora JD, Saquy PC, Sousa Neto MD, Woelfel JB. Root
form and canal anatomy of maxillary first premolars. Braz
Dent J 1991;2(2):87–94.
2. Baratto Filho F, Zaitter S, Haragushiku GA, de Campos EA,
Address for Correspondence:
Dr. Atif Saleem Agwan, Endodontist, Northern area Armed Forces Hospital, King Khalid Military City-Kingdom
of Saudi Arabia
Tel: +966-541651713
Email: dratifagwan@yahoo.com
http://www.jamc.ayubmed.edu.pk
J Ayub Med Coll Abbottabad 2016;28(3)
Abuabara A, Correr GM. Analysis of the internal anatomy of
maxillary first molars by using different methods. J Endod
2009;35(3):337–42.
3. al Shalabi RM, Omer OE, Glennon J, Jennings M, Claffey
NM. Root canal anatomy of maxillary first and second
permanent molars. Int Endod J 2000;33(5):405–14.
4. Vertucci FJ. Root canal anatomy of the human permanent
teeth. Oral Surg Oral Med Oral Pathol 1984;58(5):589–99.
5. Carns EJ, Skidmore AE. Configurations and deviations of
root canals of maxillary first premolars. Oral Surg Oral Med
Oral Pathol 1973;36(6):880–6.
6. Bellizzi R, Hartwell G. Radiographic evaluation of root canal
anatomy of in vivo endodontically treated maxillary
premolars. J Endod 1985;11(1):37–9.
7. Vertucci F, Seelig A, Gillis R. Root canal morphology of the
human maxillary second premolar. Oral Surg Oral Med Oral
Pathol 1974;38(3):456–64.
8. Vertucci FJ, Gegauff A. Root canal morphology of the maxillary
first premolar. J Am Dent Assoc 1979;99(2):194–8.
9. Sieraski SM, Taylor GN, Kohn RA. Identification and
endodontic management of three-canalled maxillary
premolars. J Endod 1989;15(1):29–32.
10. Javidi M, Zarei M, Vatanpour M. Endodontic treatment of a
radiculous maxillary premolar: a case report. J Oral Sci
2008;50(1):99–102.
11. Arisu HD, Alacam T. Diagnosis and treatment of three-
rooted maxillary premolars. Eur J Dent 2009;3(1):62–6.
12. Soares J, Leonardo RT. Root canal treatment of three‐rooted
maxillary first and second premolars–a case report. Int Endod
J 2003;36(10):705–10.
13. Kulid JC, Peters DD. Incidence and configuration of canal
systems in the mesiobuccal root of maxillary first and second
molars. J Endod 1990;16(7):311–7.
14. Cleghorn BM, Christie WH, Dong CC. Root and root canal
morphology of the human permanent maxillary first molar: a
literature review. J Endod 2006;32(9):813–21.
15. Woelfel JB, Scheid RC, Dental anatomy: its relevant to
dentistry, 5th edn. Williams & wilkins, USA; 1997.
16. Rhodes JS. Advanced endodontics: clinical retreatment and
surgery. CRC Press 2005.
17. Gulabivala K. Advances in endodontics. Prim Dent Care
2000;7(3):105–7.
18. Karumaran CS, Gunaseelan R, Krithikadatta J. Microscope-aided
endodontic treatment of maxillary first premolars with three
roots: A case series. Indian J Dent Res 2011;22(5):706–8.
19. Peters OA. Accessing root canal systems: knowledge base and
clinical techniques. Endod Practice Today 2008;2(2):87–104.
20. Cantatore G, Berutti E, Castellucci A. Missed anatomy:
frequency and clinical impact. Endod Top 2006;15(1):3–31.
21. Taylor G. Advanced techniques for intracanal preparation
and filling in routine endodontic therapy. Dent Clin North
Am 1984;28(4):819–32.
22. Weine, F.S., Endodontic therapy. Mosby 1976.
629